Form 1455

RESET

For official use only: Customer Name

Customer No.

PD F 1455 E Department of the Treasury Bureau of the Public Debt (Revised July 2011)

REQUEST BY FIDUCIARY FOR DISTRIBUTION OF UNITED STATES TREASURY SECURITIES

OMB No. 1535-0012

www.treasurydirect.gov

IMPORTANT: Follow instructions in filling out out this form. You should be aware that the making making of any false, false, fictitious, or fraudulent claim or statement to the United States is a crime that is punishable by fine and/or imprisonment. PRINT IN INK OR TYPE ALL INFORMATION

One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of United States Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an estate, attainment of majority, restoration to competency, or other reason.

PART A – REASON FOR DISTRIBUTION I/We request distribution of the securities and/or related payments for the following reason: Termination of trust Distribution of an estate Payment to the estate Reissue to the estate Distribution to person(s) entitled*

* If payment is requested by person(s) entitled, a PD F 1522 is required. If reissue to add another person is requested by person(s) entitled, a PD F 4000 is required. If reissue to a trust is requested, a PD F 1851 is required. NOTE: Savings bonds within one month of final maturity cannot be reissued. Attainment of majority Restoration to competency Other:

PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS I/We request that the securities and/or related payments be distributed as follows:

1. Distribute to: (Name)

OR

(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities and/or related payments: TITLE OF SECURITY

3. Extent of distribution:

ISSUE DATE

FACE AMOUNT

IDENTIFYING NUMBER

In full (Amount, Fractional Share, or Percentage)

REGISTRATION

PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS (Continued) I/We request that the securities and/or related payments be distributed as follows:


OR (Social Security Number)





ISSUE DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION


I/We request that the securities and/or related payments be distributed as follows:


OR (Social Security Number)





ISSUE DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION


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PD F 1455 E

PART C - SIGNATURES AND CERTIFICATIONS I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our knowledge and belief, and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, and to indemnify unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest, administrative costs, and penalties. I/We consent to the release of any information regarding this transaction, including information contained in this form, to any party having an ownership or entitlement interest in the securities or payments. You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here: (Signature)

(Applicant’s Title)

(Number and Street, Rural Route, or PO Box)

(City)

(Daytime Telephone Number)

(State)

(ZIP Code)

(E-Mail Address)

Instructions to Certifying Officer: 1. Name of person(s) who appeared and date of appearance MUST be completed. 2. Medallion stamps require an original signature. 3. Person(s) must sign in your presence.

I CERTIFY that

, whose identity is known or (Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

, (Month/Year)

, and signed this form.

at (City, State)

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP OR SEAL)

Name of Financial Institution

(Address)

ACCEPTABLE CERTIFICATIONS: Financial Institution’s Official Seal or Stamp (such as Corporate Seal, Signature Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion Stamp.

(City, State, ZIP Code)

(Telephone)

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PD F 1455 E

You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here: (Signature)

(Applicant’s Title)

(Number and Street, Rural Route, or PO Box)

(City)

(State)

(Daytime Telephone Number)

(ZIP Code)

(E-Mail Address)

Instructions to Certifying Officer: 1. Name of person(s) who appeared and date of appearance MUST be completed. 2. Medallion stamps require an original signature. 3. Person(s) must sign in your presence.

I CERTIFY that

, whose identity is known or (Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

, (Month/Year)

, and signed this form.

at (City/State)

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP OR SEAL)

Name of Financial Institution

(Address)

ACCEPTABLE CERTIFICATIONS: Financial Institution’s Official Seal or Stamp (such as Corporate Seal, Signature Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion Stamp.

Cit , State, ZIP Code

(Telephone)

INSTRUCTIONS USE OF FORM – One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of United States Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an estate, attainment of majority, restoration to competency, or other reason. If more space is needed for any item, use a plain sheet of paper or make photocopies, as necess ary, and attach to the form.

PART A – REASON FOR DISTRIBUTION Mark a box to show the reason for the distribution. If you mark “Other,” describe the reason.

Submit a copy of all evidence that establishes your authority to request this transaction. For example, if you are the administrator or executor of an estate, provide a certified copy of your letters of appointment, dated within one year of submission. Submit certified copies of death certificates for all deceased registrants.

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PD F 1455 E

PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS Complete Items 1 through 3.

1.

Enter the name of only one distributee in each Part B, Item 1. (A separate Part B must be completed for each distributee.) Enter the appropriate Social Security Number or Employer Identification Number.

2.

Describe only the securities and/or checks which the person shown in Item 1 is to receive, in whole or in part: TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity d ate, as appropriate. If describing a check, insert the word “check.”

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

ISSUE DATE – Provide the issue date of each security or check.

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FACE AMOUNT – Provide the face amount (par or denomination) of each security or check. IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the check number.

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REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.

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EXAMPLES:

TITLE OF SECURITY

ISSUE DATE

FACE AMOUNT

Paper Marketable Security

9 1/8 % TREASURY BOND OF 2004-2009 MATURES 5/15/09 CUSIP 912810CG1 Electronic Marketable Security

CUSIP 912795QW4

Electronic Series I Savings Bond

SERIES I

Paper Series EE Savings Bond

SERIES EE

Check

CHECK

IDENTIFYING NUMBER Serial #

5/15/79

$5,000

2/5/04

$1,000

1/1/02

$100

7/99

$100

7/26/04

$351.02

123

REGISTRATION JOHN DOE AND JANE DOE SSN 222-22-2222 ACCT # 4800-123-1234 JOHN DOE SSN 222-22-2222

Confirmation #

12345 Serial #

C-123,456,789-EE

ACCT # N-111-111-111 JOHN DOE SSN 222-22-2222 JOHN DOE OR JANE DOE

Check #

502123456

JOHN DOE

If unsure what to provide i n each of the areas, furnish all identifying information in the space for REGISTRATION.

3.

Mark the box “In full” if the person listed in Item 1 is to receive the entire value of the securities and/or checks described in Item 2. If the person listed in Item 1 is not to receive the entire value, mark the second box and provide the appropriate amount, fractional share, or percentage he/she is to receive.

In most cases, we will need additional forms and/or information from the distributee. If so, we may contact the distributee directly. If the transaction can be processed without additional forms or information from the distributee, we will send the securities and/or payments directly to the distributee. Note: If the distributee wants payment of eligible paper securities and the securities are:  

Savings bonds or notes, he/she must complete the request on the reverse of the bond. Marketable securities, the fiduciary must complete the assignment on the reverse of the security. The distributee must complete IRS Form W-9.

Any interest that is or becomes due on securities belonging to the estate of the decedent will be paid to the person to whom the securities are distributed, unless otherwise requested.

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PD F 1455 E

PART C – SIGNATURES AND CERTIFICATIONS SIGNATURES – The form must be signed in ink. Sign the form in your fiduciary capacity. If the request is on behalf of a corporate fiduciary, the name of the corporation must be given, followed by the signature and title of an authorized officer. If there are two or more fiduciaries, all must join in the request unless by express statute, decree of court, or the terms of the instrument under which the fiduciaries are acting, one or more of them may properly execute the request. CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an authorized certifying officer. The signatures to the form must be signed in the officer’s presence. The certifying officer must affix the seal or stamp which is used when certifying requests for payment. Authorized certifying officers are available at most financial institutions, including credit unions. Sample certification for a financial institution:

Acceptable certification for a brokerage:

SIGNATURE GUARANTEED

SIGNATURE GUARANTEED

ABC National Bank

MEDALLION GUARANTEED

Hillview Branch

Generic Brokerage

Authorized Signature

Authorized Signature XXXXXXXX SECURITIES TRANSFER AGENTS MEDALLION PROGRAM [Bar Code]

ADDITIONAL EVIDENCE – The Commissioner of the Public Debt, as designee of the Secretary of the Treasury, reserves the right in any particular case to require the submission of additional evidence. RETURN OF EVIDENCE – If you want the evidence submitted with this form returned to you, please provide a written request when you submit the form and evidence. WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send to the Department of the Treasury, Bureau of the Public Debt, using the appropriate address below:  

Series H or Series HH savings bonds – PO Box 2186, Parkersburg, WV 26106-2186 Definitive (paper) savings bonds – PO Box 7012, Parkersburg, WV 26106-7012

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Book-entry savings bonds and marketable se curities held in TreasuryDirect – PO Box 7015, Parkersburg, WV 26106-7015 Marketable securities held in Legacy Treasury Direct – PO Box 426, Parkersburg, WV 26106-0426

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Definitive (paper) marketable securities – PO Box 426, Parkersburg, WV 26106-0426

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NOTICE UNDER PRIVACY ACT AND PAPERWORK REDUCTION ACT The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the United States. The furnishing of a Social Security Number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109). The purpose of requesting the information is to enable the Bureau of the Public Debt and its agents to issue securities, process transactions, make payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information Public Debt may be unable to process transactions. Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to distribution or payment; agents and contractors to administer the public debt; agencies or entities for debt collection or to obtain current addresses for payment; agencies through approved computer matches; Congressional offices in response to an inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation. We estimate it will take you about 30 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to this address; send to the appropriate address shown in "WHERE TO SEND" in the Instructions.

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PD F 1455 E

Form 1455

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